Please if you can, help answer a question below about insurances paying for procedures?
We have Anthem insurance. My doctor has recommended I try several alternative treatments before surgery is required down the road. (a spinal fusion) I am wondering, will the insurance company balk on paying for the surgery if the doctor wants to try other methods first, a extended treatment with therapy, injections, nerve ablation being some of the options, but the patient is wanting to have the surgery in which he does not recommend at this time. Thanks. Just curious and will help me make a determination if anyone can answer this.
Tags: answer, below, Help, Insurance Company, insurances, Paying, please, procedures, Question
Typically insurance companies would like for you to try alternative treatments before resorting to surgery. Most doctors know how to bill procedures so that they will get paid. Doctors have to provide diagnostic information that supports the need for surgery. If there isn’t sufficient documentation to support it they can make you go through the other stuff first before they’ll cover it.
I don’t see why they would not. It would be a lot cheaper than surgery. Do call your Ins. to see if they will. You would be under doctor’s orders so there should be no problem. Hope things come through for you.XX Poppy
Your Dr recommends these conservative treatments first since they do sometimes take the need for surgery away for some years. Most insurance companies are happy to pay the cost for the conservative treatments though since your Dr is does not recommend the surgery at this time. You could always seek a second opinion about it – I did. My first one suggested the conservative treatments which only made my pain worse and my quality of life suffer needlessly. The second one I went to after having the injections, physical therapy tried drug treatment but that was on;ly masking the pain, it was not fixing the problem. 5 months after I got that second opinion I was scheduled for the spinal fusion surgery. I prefered to have the surgery done from the very first since I wanted to fix the problem and go on with life rather than extending the agony. You might tell your current Dr that you would prefer to have the surgery now and find out why he is so against it. Or you might take your records to another Dr – an ortho or neuro – and see if they recommend it now. My tratments werent working since I had blown discs, meaning all the treatments in the world would not help since the pain was from bone on bone contact. I don’t know what is going on in your spine but never hurts to get a second or even third opinion! My second opinion was from an ortho surgeon. You can alos call your insurance company but I don’t recommend it as they take what your Dr says to base their opinions on. The Dr’s at the insurance co look at your record and that is when they decide to pay or not. Best of luck to you, I do know what you are going through.
Your doctor needs to send a written plan to your insurance company, to the pre-certification department. It doesn’t matter if the procedures work or not–if he doesn’t present the plan and get it approved, they won’t pay for it. He needs to make sure all of these procedures are covered procedures (1st step) and make sure that 2) if they don’t work, surgery will still be covered. The number should be on the back of your ID card, and you need to hold to feet to the flames to make sure he gets it done, before you have any of the procedures. Otherwise, you will be responsible for any claims not covered by your plan.
I must say that ?!?!?!? is right! If your ins co does not think that you have explored all means of treatment, they may refuse to approve surgery. Or they may give approval—but they DO NOT GUARANTEE payment of claims. That is a disclaimer that we hear everyday @ work when verifying Patients insurance. It sucks!!!!
Also keep in mind when or if you do have surgery, that you will have 3 different charges…the doctor, the facility & anesthesia….all 3 are always costly!!
ps-Best of luck to you!!! I hope that you find something to ease the pain–please don’t get too dependant on pain medication!
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Think hard and fast about spinal surgery. It only improves the situation about 1/3 of the time. Another third, there’s no improvement, and the last third, it actually makes the situation worse.
Anthem will probably NOT pay for the surgery, until safer, cheaper, and more effective alternative methods have been tried.